Record Keeping and Confidentiality Policy

Good care records and strong confidentiality for care services – Regulation 17, digital social care records, the Caldicott Principles and the Data Security and Protection Toolkit.

Editable Word document
14
10pages
Guidance notes included
aml consultancy solutions

Care providers

Record Keeping and Confidentiality Policy

About this document

What it’s for

A policy for creating, using, sharing, storing and disposing of care records and other confidential information in a care service. It covers the standards for good care notes, digital social care records, information sharing for direct care, the eight Caldicott Principles, subject access requests, data breaches, retention and the annual DSPT.

When to use it

  • As your core information governance policy for CQC and the DSPT
  • When introducing or changing a digital care record system
  • In induction and annual data security training for all staff

What’s inside

The document is laid out in the sections below. Each one comes with a plain-English guidance note explaining what it does and what to change.

  1. Purpose
  2. Scope
  3. Legal and regulatory framework
  4. Definitions
  5. Roles and responsibilities
  6. Standards for good care records
  7. Digital social care records
  8. Paper records
  9. Confidentiality and the Caldicott Principles
  10. Sharing information
  11. Individuals’ rights and subject access requests
  12. Data breaches and confidentiality incidents
  13. Retention and disposal
  14. The Data Security and Protection Toolkit
  15. Training, audit and review
  16. Related documents

Also included

  • If you operate outside England
  • Staff confirmation of reading

How to complete it

  • Name your data protection lead, Caldicott lead and SIRO-equivalent in clause 5
  • Describe your digital and paper systems in clauses 7 and 8
  • Set your retention periods in Appendix C after checking the current Records Management Code
  • Have every worker sign the confidentiality agreement (Appendix A)

Key points to check

  • DSPT submission deadline and version for the current year
  • Data (Use and Access) Act 2025 changes, including complaints handling, as they come into force

Our templates are professionally structured starting points for UK businesses, not legal advice. For anything complex, unusual or high-value, have your final version checked by a solicitor.

Included in the pack

Care providers

£20

for every document in this category

Editable Microsoft Word files

Guidance notes in every document

Written for UK businesses

Download and keep

Get the packSee every document in this pack →

Need more than one category?

Documents All-Access gives you every category for 12 months for £295.

Compare options →

Need it tailored?

We can adapt any template to your business, or write a document from scratch.

Talk to us →