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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Documentation and Care Records Policy

1. Purpose

The purpose of this policy is to establish clear standards for accurate, lawful and professional documentation completed by temporary workers supplied by {{org_field_name}} while they are working at a client or hirer placement.

{{org_field_name}} operates as an employment business supplying temporary workers to client organisations. It does not provide regulated care in its own right and does not assume responsibility for the client’s statutory care records, care planning, clinical governance or CQC registration obligations.

Temporary workers supplied by {{org_field_name}} must complete all placement records accurately, promptly and in accordance with the client’s policies, systems, care plans, professional standards and lawful instructions. This includes paper records, electronic care records, observation charts, medication records, incident reports, safeguarding records and communication logs where these are required by the placement.

This policy supports compliance with applicable legislation and guidance, including the Employment Agencies Act 1973, the Conduct of Employment Agencies and Employment Businesses Regulations 2003, the Agency Workers Regulations 2010, the Data Protection Act 2018, UK GDPR, the Health and Safety at Work etc. Act 1974, the Equality Act 2010, the Mental Capacity Act 2005, the Safeguarding Vulnerable Groups Act 2006, the Police Act 1997, the Rehabilitation of Offenders Act 1974 and the Nursing and Midwifery Council Code where applicable.

2. Scope

This policy applies to all temporary workers supplied by {{org_field_name}}, including registered nurses, healthcare assistants, support workers and any other workers supplied to health or social care clients.

This policy applies to records that temporary workers are required to complete during a placement, including but not limited to:

• daily care notes;
• clinical observations;
• fluid, food, repositioning and other monitoring charts;
• medication administration records, where the worker is authorised, competent and instructed to complete them;
• incident, accident and near-miss forms;
• safeguarding concern records;
• communication notes;
• electronic care record entries;
• handover notes required by the client.

Client care records remain the property and responsibility of the client or hirer. {{org_field_name}} will only access, receive, store or process copies of such records where this is necessary for a lawful purpose, including safeguarding, incident management, complaint handling, investigation, audit, contractual compliance, legal claims, professional referral, or regulatory cooperation.

This policy applies to both handwritten and electronic documentation.

3. Related Policies

This policy should be read alongside the following policies and procedures:

• Confidentiality and Data Protection Policy;
• Data Retention and Records Management Policy;
• Recruitment, Vetting and Selection Policy;
• Right to Work Policy;
• DBS and Safer Recruitment Policy;
• Agency Worker Rights and Equal Treatment Policy;
• Health and Safety Policy;
• Safeguarding Adults Policy;
• Safeguarding Children Policy, where applicable;
• Consent, Mental Capacity and Best Interests Policy;
• Incident Reporting Policy;
• Medication Policy, where applicable to the roles supplied;
• Whistleblowing Policy;
• Complaints Policy;
• Training and Development Policy;
• Professional Registration and Fitness to Practise Policy.

4. Policy Statement

{{org_field_name}} is committed to ensuring that all records produced and maintained by its staff are:

• Accurate and factual.
• Timely and contemporaneous.
• Complete and comprehensive.
• Legible and written in plain English.
• Confidential and compliant with data protection legislation.
• Clear, respectful, and free from discriminatory, offensive, or judgemental language.

Documentation will be regarded as a vital part of the delivery of care and will form part of clinical governance and quality assurance.

{{org_field_name}} recognises that the client or hirer is normally responsible for the creation, maintenance, storage and retention of service-user care records. Temporary workers supplied by {{org_field_name}} must contribute to those records accurately and professionally while on placement, but must not remove, copy, photograph, download or retain client records unless expressly authorised and where there is a lawful and necessary reason to do so.

5. Responsibilities

Directors / Senior Management

The directors or senior management of {{org_field_name}} are responsible for ensuring that:

• workers receive appropriate induction and refresher training on documentation, confidentiality, safeguarding, data protection and placement reporting requirements;
• workers are informed that they must follow the client’s documentation systems and local procedures;
• appropriate recruitment, identity, right to work, qualification, professional registration, employment history, reference and DBS checks are completed before workers are supplied, where relevant to the role;
• hirers are provided with relevant information about the worker’s identity, qualifications, training, experience and suitability for the assignment, in accordance with the Conduct of Employment Agencies and Employment Businesses Regulations 2003;
• known health and safety risks and any steps taken by the hirer to prevent or control those risks are obtained and communicated to the worker where relevant;
• concerns about poor documentation are reviewed and acted on through supervision, retraining, investigation, removal from placement, disciplinary action or professional referral where appropriate;
• any information suggesting that a worker may be unsuitable for an assignment is assessed promptly and, where required, communicated to the hirer.

Temporary Workers

All temporary workers supplied by {{org_field_name}} must:

• complete records accurately, objectively, legibly and promptly;
• follow the client’s documentation policies, electronic systems, paper forms and reporting lines;
• only document care, support, observations or events that they have personally provided, witnessed or been instructed to record;
• never falsify, backdate, pre-complete, delete, conceal or improperly amend records;
• clearly identify themselves on each entry using their name, role, signature or electronic login, as required by the client’s system;
• escalate concerns, omissions, errors, safeguarding issues, medication issues, incidents, near misses or changes in a service user’s condition to the client’s person in charge before leaving the placement, unless emergency escalation is required sooner;
• notify {{org_field_name}} of any documentation concern, incident, complaint, safeguarding matter, data breach or professional concern as soon as reasonably practicable;
• maintain confidentiality and comply with UK GDPR and the Data Protection Act 2018.

Client / Hirer Responsibilities

The client or hirer is responsible for:

• providing safe systems of work and appropriate instructions to temporary workers;
• giving workers access to the records, care plans, risk assessments and documentation systems needed for the assignment;
• explaining local documentation procedures, including electronic record systems, login arrangements and escalation routes;
• ensuring that agency workers are not asked to work outside their competence, authorisation, professional registration or agreed assignment terms;
• maintaining, storing and retaining service-user care records in accordance with the client’s own legal, contractual and regulatory obligations;
• reviewing records completed by agency workers where this forms part of the client’s governance arrangements;
• informing {{org_field_name}} promptly of any documentation concerns, safeguarding concerns, incidents, complaints or suspected misconduct involving an agency worker.

6. Legal and Regulatory Requirements

{{org_field_name}} will operate this policy in line with applicable legislation and guidance, including:

• Employment Agencies Act 1973;
• Conduct of Employment Agencies and Employment Businesses Regulations 2003;
• Agency Workers Regulations 2010;
• Employment Rights Act 1996;
• Working Time Regulations 1998;
• National Minimum Wage Act 1998 and National Minimum Wage Regulations 2015;
• Equality Act 2010;
• Immigration, Asylum and Nationality Act 2006;
• Data Protection Act 2018 and UK GDPR;
• Health and Safety at Work etc. Act 1974;
• Safeguarding Vulnerable Groups Act 2006;
• Police Act 1997;
• Rehabilitation of Offenders Act 1974 and the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975;
• Mental Capacity Act 2005;
• Modern Slavery Act 2015, where applicable;
• Nursing and Midwifery Council Code, for registered nurses;
• applicable client policies, local safeguarding procedures and contractual requirements.

Where a client is a CQC-registered provider, agency workers must comply with the client’s lawful policies and documentation requirements. However, {{org_field_name}} does not provide regulated care and does not rely on this policy as evidence of CQC registration.

7. Principles of Good Record Keeping

Staff must adhere to the following principles when completing documentation.

Records must be:

• Accurate: Facts must be recorded truthfully and verified.
• Clear: Avoid ambiguity, jargon, or abbreviations unless they are widely accepted.
• Legible: Handwritten records must be readable and written in black ink.
• Contemporaneous: Record information as soon as possible after the event or intervention.
• Signed and dated: All entries must include the staff member’s full name, signature, and designation.
• Confidential: Only shared on a need-to-know basis in accordance with data protection legislation.
• Respectful: Avoid subjective or judgemental comments. Records must never be altered, falsified, or backdated.

Where an error is made, staff must follow the client’s correction procedure. As a minimum, the original entry must remain visible, the correction must be dated and timed, and the person making the correction must be identifiable.

Staff must not use another person’s electronic login, password, smartcard, signature or identity. Staff must log out of electronic systems when not in use and must report any suspected unauthorised access immediately.

Staff must not make unofficial notes about service users on personal devices, messaging applications, photographs, cloud storage, notebooks or removable media. Any temporary note made for immediate handover purposes must be transferred into the client’s authorised record system and securely destroyed before the worker leaves the placement, unless the client instructs otherwise.

8. Content of Placement Records

Where required by the client’s care plan, risk assessment, local procedure or lawful instruction, workers must record:

• All care provided, including personal care, nutritional support, repositioning, or social engagement.
• Clinical observations (e.g., blood pressure, temperature, pulse, blood glucose) as required by the care plan.
• Medication administration where authorised and trained to do so.
• The individual’s response to care.
• Changes in condition, behaviour, or emotional wellbeing.
• Discussions with family members or advocates where relevant.
• Safeguarding concerns, incidents, or accidents following local reporting protocols.
• Actions taken and who was informed.

• refusal of care, treatment, food, fluids, medication or support, including who was informed;
• missed, delayed or incomplete care, including the reason and escalation taken;
• any limitations on the worker’s ability to complete required documentation before leaving the placement;
• any instruction that appears unsafe, unlawful, discriminatory or outside the worker’s competence, including escalation to the person in charge and to {{org_field_name}}.

9. Electronic Record Keeping

Where electronic records are used:

• Staff must follow the client’s protocols for logging, entering, and securing information.
• Passwords and access credentials must never be shared.
• Only agency staff who have received training on the system may use it.
• Electronic records must comply fully with the same legal, professional, and ethical standards as paper records.

Workers must only access electronic records for individuals whose care, treatment or support they are directly involved in during that placement. Accessing records out of curiosity, for personal reasons, or without a work-related need is prohibited and may result in disciplinary action, removal from placement, notification to the client, professional referral and/or reporting as a data protection incident.

Workers must not download, photograph, screenshot, print, email or transfer electronic records unless expressly authorised by the client and where this is necessary for a lawful work-related purpose. Any suspected cyber incident, lost device, unauthorised access, misdirected email, shared password, incorrect record entry or data breach must be reported immediately to the client and to {{org_field_name}}.

10. Confidentiality

All records are confidential and must be handled in accordance with {{org_field_name}}’s Confidentiality and Data Protection Policy. Staff must:

• Only access records required to carry out their role.
• Share information only with authorised individuals on a need-to-know basis.
• Store completed documentation securely at the placement site.
• Never remove service user records from the care setting.
• Report any data breaches immediately to the client and to {{org_field_name}}.

Where {{org_field_name}} receives personal data, special category data or criminal offence data relating to workers, candidates, clients or service users, it will process such information only where it has a lawful basis under UK GDPR and the Data Protection Act 2018. Special category data and criminal offence data must be handled with additional safeguards, including access controls, confidentiality, retention limits and secure disposal.

The Data Protection Act 2018 requires an appropriate policy document in certain circumstances where special category data is processed for employment, social security, social protection or substantial public interest reasons. {{org_field_name}} will maintain appropriate data protection documentation where required.

11. Data Retention and Record Ownership

Client care records must remain at the placement location or within the client’s authorised electronic system unless the client gives clear authorisation for another lawful arrangement.

{{org_field_name}} will not routinely retain copies of service-user care records. Where copies or extracts are received because of an incident, safeguarding concern, complaint, investigation, audit, legal claim, professional referral or contractual requirement, they will be:

• limited to what is necessary;
• stored securely with restricted access;
• used only for the purpose for which they were obtained;
• retained only for as long as necessary under the applicable retention schedule;
• securely deleted, destroyed or returned when no longer required.

Workers must not keep personal copies of care records, incident forms, medication records, photographs, screenshots, handover notes or service-user information.

12. Record Keeping in Relation to Mental Capacity

Workers must follow the Mental Capacity Act 2005, the client’s policies and the client’s care plans when supporting individuals who may lack capacity for a specific decision.

Workers must record relevant information factually, including:

• whether consent was sought and whether it was given, refused or withdrawn;
• any concerns that the person may not understand, retain, use or weigh relevant information, or communicate their decision;
• any immediate action taken to keep the person safe;
• who was informed, including the nurse in charge, senior carer, manager, family member, advocate or other professional, where appropriate;
• any best interests decision that the worker was directly involved in, where the client’s procedure requires this to be documented.

Workers must not make formal capacity assessments or best interests decisions unless this is within their role, competence, professional registration, client authorisation and the circumstances of the placement.

13. Incident Reporting

Staff must:

• Complete incident forms promptly and accurately following any accident, near-miss, safeguarding concern, or other incident.
• Follow both the placement’s and {{org_field_name}}’s incident reporting procedures.
• Record incidents factually, clearly, and without assigning blame.

Workers must report incidents, accidents, near misses, safeguarding concerns, medication errors, omissions in care, documentation errors and data breaches to the person in charge at the placement before leaving duty, unless urgent escalation is required sooner. Workers must also notify {{org_field_name}} as soon as reasonably practicable.

Where the client is a regulated provider, the client remains responsible for any statutory notification, duty of candour process or CQC notification arising from its regulated activity. {{org_field_name}} will cooperate with the client’s investigation and will take appropriate action in relation to the agency worker.

14. Consent

Workers must seek consent before providing care, support or assistance, unless there is an emergency or another lawful basis for acting. Documentation must clearly record whether consent was given, refused or withdrawn where this is relevant to the care or support provided.

Where a person appears unable to consent to a specific decision, workers must follow the client’s Mental Capacity Act 2005 procedure, act within their role and competence, and escalate concerns to the person in charge. Any action taken must be documented factually in the client’s record system.

15. Accountability and Professional Responsibility

All agency workers are personally responsible for the records they complete. For registered nurses, record keeping is an explicit requirement of the NMC Code. Poor documentation may result in disciplinary action, referral to professional bodies, and may compromise service user safety.

Registered professionals must maintain their own professional registration and practise in accordance with their professional code, scope of practice and competence. {{org_field_name}} will check professional registration where required for the role and may report concerns to the relevant professional body where documentation failures raise concerns about fitness to practise, dishonesty, safeguarding, unsafe practice or public protection.

16. Auditing and Monitoring

{{org_field_name}} will monitor compliance with this policy through proportionate measures, including:

• client feedback;
• worker supervision and appraisal;
• incident, complaint and safeguarding reviews;
• review of timesheets, assignment records and communications;
• investigation of documentation concerns raised by clients, workers or third parties;
• review of training completion and competency records.

{{org_field_name}} will not routinely audit client care records unless this is agreed with the client, lawful, necessary and consistent with data protection requirements. Where documentation concerns are identified, {{org_field_name}} may take corrective action, including further training, supervision, restriction of assignments, removal from placement, disciplinary action, referral to a professional body, or referral to safeguarding authorities where appropriate.

17. Training

All staff will receive training on:

• Principles of good record keeping.
• Documentation in the context of safeguarding, consent, and the Mental Capacity Act.
• Legal and professional obligations relating to care records.
• Confidentiality and data protection principles.
• Refresher training will be provided annually or as necessary.

• client-specific documentation and escalation procedures;
• safe use of electronic care record systems;
• data protection, confidentiality and information security;
• incident, accident, safeguarding and medication-error reporting;
• Mental Capacity Act 2005 principles and consent;
• equality, dignity and non-discriminatory record keeping;
• professional accountability and NMC record-keeping expectations, where applicable;
• right to work, DBS, safer recruitment and role suitability requirements for relevant office staff involved in recruitment and compliance.

18. Supervision and Support

{{org_field_name}} will:

• Provide staff with supervision and guidance where documentation concerns are identified.
• Offer additional support or retraining if staff experience difficulty meeting documentation requirements.
• Ensure that directors are available to respond to queries about documentation at any time.

Where a client raises concerns about a worker’s documentation, {{org_field_name}} will review the concern promptly, obtain relevant information where lawful and necessary, and decide whether the worker requires further training, supervision, removal from placement, restriction of duties, disciplinary action, safeguarding referral or professional referral.

Workers must contact {{org_field_name}} promptly if they are asked to complete records retrospectively, inaccurately, under another person’s login, outside their competence, or in a way that they believe is unsafe, unlawful or misleading.

19. Agency Worker Rights and Assignment Information

{{org_field_name}} will provide workers with required assignment information and terms in accordance with the Conduct of Employment Agencies and Employment Businesses Regulations 2003 and other applicable employment legislation.

Workers will be informed of relevant assignment details, including the identity of the hirer, location, start date, expected duration, type of work, hours, pay arrangements, required experience, training, qualifications, risks notified by the hirer, and any special requirements of the role.

{{org_field_name}} will support compliance with the Agency Workers Regulations 2010, including day-one rights and equal treatment rights after the qualifying period where applicable. {{org_field_name}} will not use any arrangement that seeks to rely on the former Swedish derogation / pay-between-assignments model.

20. Right to Work

{{org_field_name}} will complete right to work checks before a worker is supplied to any assignment. Checks will be completed in accordance with current Home Office guidance and will be recorded securely.

Where a worker has time-limited permission to work, {{org_field_name}} will monitor expiry dates and complete follow-up checks where required. Workers must not be supplied to a client unless {{org_field_name}} is satisfied that the worker has the right to undertake the work in question.

Records of right to work checks will be retained securely in accordance with Home Office requirements and {{org_field_name}}’s data retention policy.

21. DBS, Barred Lists and Safer Recruitment

{{org_field_name}} will assess each role to determine the appropriate level of DBS check and whether a barred list check is legally permitted. Enhanced DBS checks with barred list checks will only be requested where the role is eligible, including where the worker will be carrying out regulated activity with adults and/or children.

{{org_field_name}} will not supply a worker to regulated activity where it knows, or has reason to believe, that the worker is barred from that activity.

DBS certificate information will be handled securely, used only for recruitment and suitability purposes, shared only where lawful and necessary, and retained only for as long as permitted by DBS requirements and {{org_field_name}}’s retention policy.

Where {{org_field_name}} uses the DBS Update Service, status checks will only be carried out with the worker’s consent and where the original certificate is at the correct level and workforce for the role.

22. Health and Safety Information from Hirers

Before supplying a worker, {{org_field_name}} will take reasonable steps to obtain relevant information from the hirer about the assignment, including any known health and safety risks and the measures taken to prevent or control those risks.

{{org_field_name}} will provide relevant information to the worker before the assignment where practicable. Workers must follow the client’s health and safety procedures, infection prevention and control measures, moving and handling instructions, lone working procedures and incident reporting arrangements.

Workers must immediately report unsafe working conditions, inadequate equipment, lack of access to required records, unsafe staffing concerns or instructions outside their competence to the person in charge and to {{org_field_name}}.

23. Pay, Working Time and Timesheets

{{org_field_name}} will pay workers in accordance with their agreed terms, applicable minimum wage legislation, working time requirements and holiday entitlement rules.

Workers must submit accurate timesheets or electronic time records in accordance with {{org_field_name}}’s procedures. Timesheets must honestly reflect hours actually worked and must not be falsified.

{{org_field_name}} will not withhold payment properly due to a worker solely because the worker has not produced an authenticated timesheet, where the worker has otherwise carried out the work and payment is due. {{org_field_name}} may take reasonable steps to verify hours worked with the hirer.

Workers must report concerns about excessive hours, missed rest breaks, fatigue, unsafe rostering or inaccurate time records to {{org_field_name}}.

24. Equality and Non-Discriminatory Documentation

Records must be written respectfully and must not include discriminatory, offensive, stereotyped or judgemental language. Workers must not make assumptions based on age, disability, gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sex, sexual orientation or any other irrelevant personal characteristic.

Where a person’s protected characteristic, communication need, cultural need, disability, reasonable adjustment or preference is relevant to their care or support, it must be recorded factually, respectfully and only where necessary.

25. Modern Slavery and Labour Exploitation

{{org_field_name}} is committed to preventing modern slavery, human trafficking, forced labour, debt bondage, unlawful deductions, worker exploitation and coercion within its business and supply chains.

Staff involved in recruitment, compliance, payroll and client management must remain alert to indicators of exploitation, including workers being controlled by another person, unexplained deductions, withheld identity documents, inability to speak freely, excessive working hours, accommodation concerns, or signs of intimidation.

Concerns must be escalated promptly to senior management and, where appropriate, to the police, local authority safeguarding team, Gangmasters and Labour Abuse Authority or other relevant authority.

Where {{org_field_name}} meets the statutory threshold for a modern slavery statement, it will publish and maintain a statement in accordance with the Modern Slavery Act 2015.

26. Continuous Improvement

{{org_field_name}} will regularly review this policy and related procedures to ensure they remain appropriate for an employment business supplying temporary workers to health and social care clients. Reviews will take account of:

• changes in employment agency legislation;
• changes in agency worker rights;
• right to work guidance;
• DBS and safer recruitment guidance;
• data protection requirements;
• health and safety requirements;
• safeguarding learning;
• client feedback;
• complaints, incidents and investigations;
• professional standards, including NMC requirements where applicable.

Lessons learned from incidents, complaints, safeguarding concerns, audits and client feedback will be used to improve worker training, recruitment checks, placement matching and documentation standards.

27. Policy Review

This policy will be reviewed at least annually or earlier where:

there are changes to DBS, right to work, agency worker, data protection or health and safety requirements.

there are changes in legislation, statutory guidance or regulatory expectations;

there are changes to the services supplied by {{org_field_name}};

{{org_field_name}} begins to provide, manage or direct regulated care activities;

feedback, complaints, incidents, audits or safeguarding concerns indicate that changes are required;

new client documentation systems, electronic care record systems or contractual requirements are introduced;

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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.