Record Keeping and Documentation Policy and Procedure

1. Governance

1.1. This is the Record Keeping and Documentation Policy and Procedure for The Good Place Home Care Services Limited.

1.2. The Good Place Home Care Services Limited will be referred to in this document as "The Good Place Home Care Services Limited","The Good Place","We","Us", or "Our".

1.3. Our registered address is: 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ.

1.4. We can be contacted by:-

• a. Telephone: 01283 296 337
• b. Email: [protected:ahello][protected:athegoodplace.care]
• c. Post: The Good Place, 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ

1.5. Words importing one gender include all genders, and words in the singular include the plural and vice versa, unless the context requires otherwise.

1.6. Document control sheet:-

2. Purpose

2.1. Ensure all care records are complete, accurate, and up to date.

2.2. To comply with CQC regulations, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and current UK data protection law (UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018).

2.3. To protect service users’ confidentiality and privacy.

2.4. To provide a clear framework for staff on how to record and maintain documentation.

2.5. To reduce the risk of errors and promote accountability in care delivery.

2.6. To ensure that we fulfil the legal and regulatory responsibilities.

2.7. To support us to meet, and be able to evidence compliance with, the following CQC Single Assessment Framework quality statements:-

3. Scope

3.1. This policy applies to and must be followed by:-

• a. All staff (including employees, agency workers, volunteers and contractors) who create, use or manage records on behalf of The Good Place.
• b. Managers and supervisors who oversee record-keeping practices, audits and information governance.

3.2. This policy also explains how record keeping affects:-

• a. Service users and their families/ representatives, by promoting transparency, accuracy and accessibility of information about their care and support.
• b. Healthcare professionals and external agencies involved in care planning, coordination and review.

3.3. All documentation related to service users must be accurate, legible, and completed in real-time to ensure continuity and quality of care.

4. Policy Statement

4.1. At The Good Place, we recognise that accurate and comprehensive record-keeping is fundamental to delivering safe, effective, and high-quality domiciliary care.

4.2. Proper documentation ensures continuity of care, legal compliance, and the protection of both service users and staff. This policy sets out our expectations, procedures, and legal requirements for maintaining clear, secure, and reliable records.

5. Legal & Regulatory Framework

5.1. This policy is guided by:-

• a. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:-
  • aa. Regulation 9: Person-Centred Care
  • ab. Regulation 12: Safe Care and Treatment
  • ac. Regulation 17: Good Governance
  • ad. Regulation 20: Duty of Candour
• b. Care Act 2014 and associated statutory guidance: Setting out adult safeguarding duties, including the requirement to keep appropriate records of concerns, referrals, enquiries and outcomes.
• c. Mental Capacity Act 2005 and accompanying Code of Practice: Requiring us to record capacity assessments, best interests decisions and any restrictions on a person’s rights in a clear and auditable way.
• d. UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018: Together forming the current UK data protection regime, governing the lawful, fair and transparent processing of personal data, including special category health and care information, and ensuring confidentiality, security and data subject rights.
• e. Common Law Duty of Confidentiality and professional codes of conduct (where applicable): Requiring us to keep personal information confidential unless there is a lawful and justifiable basis to share it.
• f. CQC’s Fundamental Standards: Ensuring compliance with best practices for documentation.

5.2. In line with Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, The Good Place maintains securely accurate, complete and contemporaneous records for each person using the service, including the care and treatment provided and decisions made about their care. We also maintain securely such other records as are necessary in relation to persons employed and the overall management of the regulated activity.

5.3. Records Management Code of Practice for Health and Social Care 2021 and the ‘Records Management – Abbreviated Code of Practice and Guidance for Adult Social Care Providers’ (Digital Care Hub, 2024): Used as the basis for our retention, storage and disposal of records, including minimum retention periods for care, staff and corporate records, and ensuring we can evidence how long records are kept and how they are securely destroyed.

5.4. The Good Place is fully committed to meeting the requirements of the Accessible Information Standard (AIS), as set out by NHS England. This means we will ensure that people with a disability, impairment, or sensory loss receive information and communication support that they can understand and use effectively. This may include large print, easy-read versions, audio formats, or the use of interpreters and communication aids. See our Accessible Information Standard (AIS) Policy and Procedure for further details.

5.5. We also comply with the Equality Act 2010 and are fully committed to promoting diversity, and human rights in all aspects of our service provision and employment practices. We are dedicated to ensuring that all individuals, including staff, service users, and stakeholders, are treated fairly, with dignity and respect, and without discrimination. We will also make reasonable adjustments so that no individual is treated less favourably when using our service. This includes supporting people with protected characteristics such as age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. See our Equality, Diversity and Human Rights Policy and Procedure for further details.

6. Types of Records Maintained

6.1. To ensure continuity, safety, and high standards of care, The Good Place maintains the records detailed below.

6.2. Service User Records

6.2.1. Care Plans

6.2.1.1. These documents provide a comprehensive overview of the service user’s individual needs, preferences, medical conditions, and risk factors. They outline the specific care interventions required, including dietary needs, mobility support, and medication management, ensuring a personalised approach to care.

6.2.2. Risk Assessments

6.2.2.1. Conducted regularly and updated as needed, these assessments identify potential hazards such as fall risks, home environment safety, or risks related to medical conditions. The purpose is to implement preventative measures that enhance safety and well-being.

6.2.3. Medication Administration Records (MAR Charts)

6.2.3.1. These records ensure that medication is administered accurately and safely, documenting details such as dosages, times, administration routes, and any observed side effects. This supports compliance with medication policies and regulatory standards.

6.2.4. Mental Capacity and Best Interests Records

6.2.4.1. Where there are doubts about a person’s capacity to make specific decisions, we will record capacity assessments, the decision(s) in question, who was involved, and the outcome in line with the Mental Capacity Act 2005 and its Code of Practice.

6.2.4.2. Where a person is assessed as lacking capacity for a particular decision, we will record best interests decisions, including consideration of the person’s wishes, feelings, values and beliefs, and the views of people important to them.

6.2.4.3. Any restrictions on a person’s rights or freedoms (for example, in relation to medication, access to finances or contact with others) will be clearly documented, justified and regularly reviewed.

6.2.5. Daily Care Logs

6.2.5.1. These logs provide a detailed account of daily activities, personal care tasks, meal intakes, mood observations, and any significant changes in the service user’s condition. Care staff must record all interactions and care provided to ensure continuity and effective communication between care teams.

6.2.6. Incident and Accident Reports

6.2.6.1. Any unexpected incidents, injuries, or safeguarding concerns must be immediately documented and reported. These records support investigations, risk mitigation, and compliance with safeguarding policies to ensure service users’ safety.

6.2.7. Safeguarding Records

6.2.7.1. We maintain clear and detailed records of any safeguarding concerns, disclosures, referrals to the local authority, enquiries, outcomes and learning. These records include dates, times, people involved, decisions made and actions taken, in line with the Care Act 2014 and local safeguarding adults procedures.

6.2.7.2. Safeguarding records are stored securely and are only accessible to authorised staff who need to know, in line with our Safeguarding Policy and Procedure.

6.2.8. Duty of Candour Records

6.2.8.1. For any notifiable safety incident, records will be kept of: the incident; all meetings and communications with the relevant person; the information and apology provided; any agreed actions; and all follow-up correspondence, in line with Regulation 20 (Duty of Candour). These records will be stored securely and retained in accordance with our retention schedule.

6.2.9. Communication Logs

6.2.9.1. Maintaining clear records of discussions with family members, GPs, district nurses, and other external professionals is essential for coordinated care planning. These logs ensure that service users’ care is continuously monitored and adjusted based on multidisciplinary input.

6.3. Staff and Operational Records

6.3.1. Staff Training Records

6.3.1.1. Documenting all completed training, including mandatory courses such as safeguarding, medication handling, and manual handling. This ensures that all care staff are competent and up to date with professional development requirements.

6.3.2. Supervision and Appraisal Records

6.3.2.1. Tracking individual staff performance, professional development needs, and ongoing support requirements. These records help maintain a high standard of service and staff accountability.

6.3.3. Complaints and Concerns Log

6.3.3.1. Every complaint must be documented, investigated, and responded to in line with our Complaints Policy and Procedure. This log includes the nature of the complaint, actions taken, and resolutions implemented, ensuring transparency and compliance with Regulation 16 of the Health and Social Care Act.

6.3.4. Visit Schedules, Rotas and Call Monitoring Records

6.3.4.1. We maintain accurate records of planned and actual visit times, durations and staff allocated to each visit (including any changes, delays or missed calls). These records support safe staffing, continuity of care and monitoring of service delivery.

6.3.4.2. Where electronic call monitoring (ECM) or similar systems are used, we ensure that data is accurate, securely stored and regularly reviewed to identify and address any issues.

6.3.5. Audits and Quality Assurance Reports

6.3.5.1. Regular internal and external audits are conducted to assess compliance with policies, identify areas for improvement, and ensure best practices. Quality assurance reports help maintain high standards of care and regulatory adherence.

7. Principles of Record Keeping

7.1. All staff must adhere to the 5 Key Principles of Record Keeping at The Good Place.

7.2. By maintaining high-quality record-keeping practices, The Good Place ensures that service users receive safe, coordinated, and legally compliant care while protecting their privacy and dignity.

7.3. Accuracy

7.3.1. All entries must be precise, clear, and factual, avoiding any assumptions or vague terminology. Information must reflect actual events and be written in a neutral, professional tone. Records must be indelible, so that entries cannot be removed or altered without a clear audit trail.

7.4. Completeness

7.4.1. Documentation must be comprehensive and include all relevant details. Any missing or incomplete records could result in gaps in care, misunderstandings, or safety risks.

7.5. Timeliness

7.5.1. Care records must be completed at the time of care delivery or as soon as possible thereafter. Delays in documentation could lead to errors, confusion, or legal non-compliance. This ensures that records remain up to date and reflect the person’s current needs and risks.

7.6. Confidentiality

7.6.1. Service user data must be protected at all times, in line with UK data protection law (UK GDPR and the Data Protection Act 2018). Records should be securely stored, and only authorised personnel should have access.

7.7. Legibility and Professionalism

7.7.1. Handwritten records must be clear and readable, while digital records must be free from spelling errors, abbreviations (unless approved), and ambiguous phrasing. Professional language must be used at all times, and entries must not be judgemental, discriminatory or based on personal opinion.

8. Procedures for Record Keeping

8.1. To ensure continuity of care, legal compliance, and accountability, all records at The Good Place must be completed, stored, and reviewed in accordance with best practice guidelines.

8.2. Completing Records

8.2.1. All records must be completed at the time of care delivery or immediately after to ensure accuracy and prevent any loss of crucial information.

8.2.2. Use black ink for paper records, ensuring they are clear, legible, signed, and dated. If an error occurs, a single line must be drawn through the incorrect entry, and it must be initialled and dated—erasing or using correction fluid is strictly prohibited.

8.2.3. Digital records must be securely logged, timestamped, and attributed to the responsible staff member to maintain accountability and traceability.

8.2.4. Abbreviations and jargon should be avoided unless standardised within the organisation. All entries must be professional, factual, and objective.

8.2.5. Records must be person-centred, reflecting the individual needs and preferences of the service user, and must be written in a respectful and non-discriminatory manner.

8.2.6. Observational language should be used, focusing on what was seen, heard, or reported, rather than assumptions or opinions.

8.2.7. Any care interventions, refusals of care, changes in service user condition, or incidents must be recorded immediately to ensure a complete and accurate account of events.

8.2.8.  Records must be written in a way that supports safe handover and continuity of care between care workers and other professionals. Entries should make clear what has been done, what is outstanding, and any actions required at the next visit.

8.2.9. If a service user refuses medication or any form of care, this must be documented along with the actions taken to escalate or resolve the issue.

8.3. Storing and Securing Records

8.3.1. Paper records must be stored in locked cabinets, accessible only to authorised personnel. Records must never be left unattended in open areas to prevent unauthorised access.

8.3.2. Digital records must be protected by secure passwords, encryption, and access control measures to ensure confidentiality and compliance with GDPR.

8.3.3. Service user information must never be discussed in public or shared inappropriately. Information will only be shared with other professionals or agencies where there is a lawful basis for doing so (for example, with the person’s consent, where it is necessary for the provision of care and treatment, or where there is a safeguarding or legal requirement). Staff must ensure that any discussions regarding service users take place in a secure and confidential environment.

8.3.4. Data breaches must be reported immediately to the manager or Data Protection Officer (DPO). Any suspected or actual breaches must be investigated promptly in line with data protection policies.

8.3.5. Records will be retained in line with the Records Management Code of Practice for Health and Social Care 2021 and the adult social care retention schedules (for example, adult care records are normally kept for a minimum of 8 years after the end of care, or longer where required for legal, safeguarding or regulatory reasons). Staff, HR and corporate records will be kept for the minimum periods specified in these schedules. When retention periods have expired, records will be reviewed and securely destroyed or archived in accordance with this guidance.

8.3.6. Electronic records should have regular backups to prevent data loss in the event of system failures.

8.3.7. Staff must follow access control policies, ensuring that only those with authorisation can access specific records.

8.4. Reviewing and Updating Records

8.4.1. Care plans and risk assessments must be reviewed regularly (at least every six months or sooner if significant changes occur in the service user’s condition, medication, or care needs).

8.4.2. Staff must be vigilant in updating records following changes in care interventions, new risk factors, or significant incidents. Any changes must be documented, dated, and signed off by the appropriate person to ensure traceability and accountability.

8.4.3. Audits will be conducted periodically to ensure compliance with documentation standards, identify areas for improvement, and promote best practices in record-keeping.

8.4.4. Management will regularly monitor records for completeness, accuracy, and adherence to policies, offering training and support where necessary.

8.4.5. Service users and/or their legal representatives must be involved in reviewing their care plans where possible, ensuring they remain up to date and reflect their needs and preferences.

8.4.6. Where changes to a service user’s condition occur suddenly (e.g., hospitalisation, safeguarding concerns, medication changes), records must be updated immediately, and relevant staff must be informed promptly.

8.5. Digital Record Systems

8.5.1. Where The Good Place uses digital systems to record and store information, these systems must:-

• a. Provide clear audit trails showing who made each entry, and when, and any subsequent amendments.
• b. Be accessible to authorised staff at the point of care to support safe, timely and person-centred decision-making.
• c. Meet UK GDPR and Data Protection Act 2018 requirements, with appropriate technical and organisational security measures (for example, role-based access controls, strong authentication, encryption, secure backup, disaster-recovery and protection against cyber security threats).
• d. Be configured and used in line with CQC guidance on digital records in adult social care and the Records Management Code of Practice for Health and Social Care 2021.

8.5.2. When digital and paper records both exist, staff must ensure that information is consistent across formats and that the digital record remains the primary, up-to-date source.

8.5.3. Any actual or suspected security incident affecting digital records (such as unauthorised access, loss of devices, malware or ransomware attacks) must be reported immediately in line with our Data Protection and Cyber Security Policy so that appropriate containment, investigation and notification can take place.

9. Consent and Confidentiality

9.1. At The Good Place, we uphold the highest standards of data protection, confidentiality, and informed consent in line with UK data protection law (UK GDPR and the Data Protection Act 2018). We process personal data only where we have a clear lawful basis (for example, providing health and social care, meeting legal obligations, protecting vital interests, or with the person’s consent where appropriate).

9.2. Informed consent will normally be sought where we rely on consent as the lawful basis for sharing information (for example, sharing information with a particular family member where this is not otherwise required or justified). However, we may share information without consent where this is necessary and proportionate for the provision of care and treatment, to safeguard a person at risk of abuse or neglect, to comply with a legal obligation, or for other lawful purposes set out in UK GDPR and the Data Protection Act 2018.

9.3. If there is concern that a service user may lack capacity to consent to information sharing, decisions must follow the principles of the Mental Capacity Act 2005. We will record the capacity assessment, the decision(s) in question, who was involved, and the outcome. Where a person lacks capacity for a particular decision, we will document best interests decisions about information sharing, including any safeguarding or legal considerations.

9.4. Service users have the right to access their records upon request, in line with UK GDPR (subject access). Requests should be handled promptly and, in any event, a response must be provided without undue delay and within one month of receipt, unless an extension is permitted by law and the person is informed. Requests should be logged and managed in line with our Data Protection and Subject Access Request Procedure.

9.5. Staff must follow strict confidentiality protocols, ensuring that personal data is handled lawfully. Information should only be accessed by authorised personnel and must not be discussed in public or shared inappropriately.

9.6. Paper records must be kept securely in locked storage, and digital records must be protected with passwords and encryption. Unauthorised access or disclosure of service user records may result in disciplinary action.

9.7. If a service user withdraws consent for information sharing, this must be clearly documented, and staff must ensure compliance unless legal obligations dictate otherwise.

9.8. Staff must be trained regularly on confidentiality policies, GDPR compliance, and data protection best practices to ensure ongoing adherence to legal and ethical standards.

10. Managing Record Errors and Amendments

10.1. Ensuring accuracy and integrity in record-keeping is essential to maintaining high standards of care and compliance at The Good Place. All staff must adhere to best practices when correcting errors in both paper and digital records.

10.2. Errors must not be erased or altered. If an error is identified in a paper record, a single line must be drawn through the incorrect entry, and the correction must be clearly written, initialled, and dated. The original entry must remain legible to maintain transparency.

10.3. For digital records, an audit trail must be maintained to show any changes made. Amendments should be recorded with timestamps, staff initials, and reasons for modification, ensuring a clear history of documentation updates.

10.4. If incorrect information has been recorded, staff must notify the appropriate supervisor or manager immediately. Any necessary corrections should be made as soon as possible to prevent misinformation from affecting care delivery. Where a documentation error has led to, or could lead to, harm or a significant near miss, this must also be reported as an incident in line with our Management of Accidents, Incidents, and Near Misses Policy and Procedure.

10.5. Missing information must be documented and reported to the manager. If essential data is not recorded at the time of care, staff must provide an explanation and complete the record appropriately.

10.6. Records must never be falsified, backdated, or modified in a way that misrepresents care delivery. Any suspicion of deliberate misrecording will be investigated and may lead to disciplinary action.

10.7. Staff should regularly review their documentation practices to ensure compliance with legal and organisational guidelines. Where additional training is required, managers must provide support to improve accuracy in record-keeping.

10.8. By maintaining high standards of documentation integrity, The Good Place ensures that records remain trustworthy, legally compliant, and reflective of the care provided.

11. Training and Staff Responsibilities

11.1. All relevant staff will receive training on record-keeping procedures, data protection laws, the Records Management Code of Practice for Health and Social Care 2021, Regulation 17 (Good governance) expectations, and the record-keeping aspects of Regulation 20 (Duty of Candour) as part of their induction. This training will be refreshed at appropriate intervals and whenever there are significant changes to legislation, guidance, systems or local procedures.

11.2. Managers will monitor documentation quality through regular supervision, spot checks and formal audits, and will provide additional training, coaching and support where necessary. They are responsible for ensuring that actions from audits are implemented and that learning is shared across the team.

11.3. Staff members are personally accountable for the accuracy and integrity of records they complete.

11.4. Agency, bank and temporary staff will be given appropriate instruction on our record-keeping systems and standards before working unsupervised, and are expected to follow this policy in the same way as permanent staff.