RELEVANT CHAPTERS

Record Keeping

Access to Records

1. Document Retention

All information relating to the care and support of adults in the service must be retained in line with data protection legislation (see Data Protection chapter), regulations and insurance requirements.

Access to files may be required by courts, in the case of investigations, inspections, complaints and Freedom of Information Act requests, or requests for access to files by adults themselves or their representatives (see Access to Records).

It is good practice to ensure that before files are archived content is complete, up to date and systematically organised. A system should be in place to locate files. The service must make arrangements for records to be securely archived and retrievable when required.

Specified time periods for provider services are no longer required through legislation or regulations. It is recommended good practice, however, to keep specific records for three years as outlined below. The service may wish to consider keeping records for as long as six years where possible, as this is the legislated time period for adult social care. During this time period, therefore, the local authority may request the adult’s care and support records in such circumstances detailed above.

The information below outlines what documentation should be retained and for what recommended time period.

Document type Example Period of retention
Service related documents registration documentation;

inspection documentation;

statement of aims and objectives;

statement of purpose;

meeting minutes;

non-customer related reports;

timesheets;

rotas;

safe custody records;

record of complaints;

events logs

Three years

 

Adult case files assessments;

reviews;

diary records;

correspondence;

 

Three years

 

The following records should also be kept for the periods of time stated:

  • risk assessments – until a new one replaces it;
  • purchasing excluding medical devices and medical equipment – 18 months;
  • purchasing of medical devices and medical equipment – 11 years;
  • general operating policies and procedures – retain the current version and previous version for three years;
  • any incidents, events or occurrences that require notification to the Care Quality Commission – three years;
  • use of restraint or the deprivation of liberty – three years;
  • maintenance of the premises; maintenance of equipment; electrical testing; fire safety; water safety; medical gas safety, storage and transport – three years;
  • money or valuables deposited for safe keeping – three years;
  • final annual accounts – 30 years.

After the specified period, the service should dispose of the records in a safe, confidential manner. This can be through destruction by confidential shredding, for example. If they are in electronic form they should be deleted from the computer archive. This may require the assistance of an IT expert.

2. File Organisation

It is important the contents of hard copy files are organised consistently so that information is filed correctly and can be easily located. This is vital in order to ensure the safe treatment and support of adults, including the smooth handover of care from one member of staff to another.

It is also essential to ensure that information concerning the care of the adult is easy to access to be able to respond to enquiries and enable file audit and inspection.

Contents of files should follow the guidance on recording (see Record Keeping chapter) and all content should be filed chronologically in the correct sections.

If there is a section entitled Not Cleared for Access staff should be aware of this and what content should be filed under this heading.