Reporting, Record Keeping & Information Governance in Care

Reporting, Record Keeping & Information Governance in Care

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Course Overview

When something goes wrong in a care setting, the first thing anyone looks at is the records. Not what staff remember. Not what they intended. What was written down?

This is not a technicality. It is how safeguarding investigations work, how CQC inspections go, and how legal proceedings operate. Documentation is the evidence that care was delivered, that decisions were considered, and that risks were managed. Without it, none of that can be demonstrated.

In delivery, the consequences of poor recording are consistent and serious. Incomplete records mean the care worker coming on shift does not have the full picture. A change in the individual’s condition, missed on one record and not picked up on the next, goes unaddressed. The person receiving care is placed at risk of harm because the information that should have been there was not. This happens. It is preventable. And the responsibility sits with every member of staff who writes a care record.

Poor record-keeping is not an admin problem. It is a safety problem, a compliance problem, and a direct risk to the people in your care.

This course gives care staff a clear, practical understanding of what good documentation looks like in practice, not just in theory. It covers what to record, how to record it accurately and objectively, what to leave out, and why all of it matters. It also covers information governance, including how personal data must be handled, stored, and shared under UK law, and what responsibilities staff carry in their day-to-day practice.

The course aligns with CQC Regulation 17 (Good Governance), the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the UK GDPR, the Data Protection Act 2018, and Care Certificate Standard 14.

Course Details

• Duration: Half day or full day (depending on depth required)
• Delivery: Face-to-face in-house, or remote via Zoom or Teams
• Certificate: CPD-Accredited Reporting, Record Keeping, and Information Governance
• Validity: Refresher recommended annually or in line with organisational policy
• Group size: Flexible

Who the Course Is For

This course is right for anyone who writes, reads, or contributes to care records in any setting, including:

• Care assistants and support workers in care homes, supported living, and domiciliary care
• Senior carers and team leaders
• Residential and nursing home staff
• Domiciliary care workers
• Supported living staff
• Personal Assistants supporting individuals through Direct Payments, Personal Health Budgets, or Continuing Healthcare arrangements

It is particularly relevant for staff who complete daily records and care notes, report incidents or raise concerns, handle personal or sensitive information, or whose documentation practice has been highlighted during supervision, audit, or inspection.

Why This Training Is Important

Accurate, complete, and timely documentation is one of the fundamentals of safe care. It keeps the next person informed. It flags what has changed. It records what was done, what was observed, and why decisions were made. When that information is missing, incomplete, or inaccurate, people fall through the gaps.

Under Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, providers have a legal duty to maintain accurate, complete, and contemporaneous records in respect of each person using the service. This is not guidance or best practice. It is a statutory requirement, and CQC inspectors assess compliance with it directly. A service that cannot demonstrate through its records that care was delivered safely, that risks were identified and managed, and that concerns were escalated appropriately is a service with significant regulatory exposure.

CQC Regulation 17 requires providers to maintain an accurate, complete and contemporaneous record in respect of each service user. CQC inspectors look at the quality of records during every inspection, including whether they are factual, whether they reflect the individual’s current needs, and whether changes in condition have been identified and acted on. Poor records do not just attract inspection findings. They signal a wider problem with governance and oversight that affects the overall rating.

The data protection side of this is equally significant. The UK GDPR and Data Protection Act 2018 set clear requirements for how personal data, including care records, must be handled. Data must be processed lawfully, stored securely, kept accurate and up to date, and shared only where there is an appropriate legal basis to do so. In a care setting, that means every member of staff who handles personal information has legal responsibilities that go beyond good intentions. This course ensures they understand what those responsibilities are in practice.

Care Certificate Standard 14 sets out the expected knowledge and competence for care workers in relation to keeping information about individuals confidential. This course covers Standard 14 in full and ensures learners understand both the practical and legal dimensions of their obligations.

What You Will Learn

By the end of the session, learners will be able to:

• Explain the purpose of reporting and record keeping in care and why documentation quality directly affects the safety of the people being supported
• Recognise what good documentation looks like and describe the difference between a record that meets the required standard and one that does not
• Record information clearly, accurately, objectively, and as close to the time of the event as possible
• Understand what should and should not be included in a care record, including the difference between factual observation and personal opinion
• Identify common documentation errors, including vague language, incomplete entries, and judgmental recording, and understand how to avoid them
• Understand their responsibilities under the UK GDPR and Data Protection Act 2018 in relation to personal data held in care records
• Apply the principles of Care Certificate Standard 14 in their day-to-day practice
• Handle, store, and share personal information securely and lawfully
• Understand the boundaries of information sharing in a care context, including when sharing is required and when it is not
• Report incidents and raise concerns through the correct channels, and understand why timely and accurate incident recording matters
• Understand how records support safeguarding, care quality, and regulatory compliance

Course Content

• The role of documentation in care
• Principles of good record keeping
• Factual and objective recording
• Incident reporting
• Communication between staff
• Information governance and confidentiality
• UK GDPR and data protection principles
• Secure storage and handling of personal information
• Sharing information appropriately and lawfully
• Care Certificate Standard 14
• Legal and regulatory context
• Common documentation errors and how to avoid them

How the Course Is Delivered

Training is delivered face-to-face at your workplace or chosen venue, or remotely via Zoom or Sessions are practical, discussion-based, and grounded in the real documentation challenges care workers face. The aim is a genuine shift in how staff think about and approach record keeping, not a passive overview of why it matters.

Delivery includes:

• Real examples of documentation done well and done poorly, including records where incomplete or vague entries contributed directly to risk
• Scenario-based discussion covering the documentation decisions staff face in everyday practice
• Practical exercises in factual and objective recording, including identifying and correcting common errors
• Review of your organisation’s own documentation systems, policies, and any specific audit or inspection feedback where relevant
• Time for questions, because record keeping consistently generates them once staff start examining their own practice honestly

Where helpful, we incorporate your own care records, documentation formats, and organisational policies directly into delivery. That is not an add-on. It is how training translates into practice rather than staying in the training room.

Certification and Validity

On completion, learners receive a CPD-accredited certificate of achievement in Reporting, Record Keeping and Information Governance in Care.

A refresher is recommended every 1 to 2 years, or sooner following significant changes to UK data protection legislation or CQC guidance, where audit or inspection feedback identifies documentation gaps, or following any safeguarding investigation where record keeping quality was a contributing factor. Many organisations align this training with their annual governance and compliance review cycle.

In-House and Bespoke Training

All training is delivered in-house or remotely and built around your organisation’s needs.

We can:

• Align training with your documentation systems and formats
• Support teams where experience levels vary
• Focus on specific audit findings or inspection outcomes
• Draw on examples from your own service

This isn’t off-the-shelf content with your logo on it. It’s training designed to work for your team, your service, and your staff.

Course Location and Service Areas

We deliver in-house training at your workplace or chosen venue, which means your staff learns in the environment they actually work in, using the systems they actually use.

Our trainers work across Manchester and Greater Manchester, with regular delivery throughout the North West. We also deliver nationwide, covering the North East, Midlands, London, Surrey, and across South England via our experienced associate network.

Every session, wherever it’s delivered, is held to the same Prima Cura standard.

FAQs

Related Courses

• Care and Support Planning
• Person Centred Care and Planning
• Safeguarding Adults Training
• Mental Capacity Act and DoLS Training
• Duty of Care
• Confidentiality & Data Protection

Book or Enquire

If your organisation wants to strengthen documentation, reduce risk, and give staff the clarity they need to record well, get in touch, and we’ll sort out a session that works for you.

Our Commitment to Quality and Compliance

At Prima Cura Training, all courses reflect current UK guidance and best practice.

All trainers are experienced professionals with relevant qualifications and ongoing CPD. Because many of the organisations we support work with vulnerable individuals, all trainers hold Enhanced DBS checks.

Training is regularly reviewed against updates from the Care Quality Commission, the Information Commissioner’s Office, and UK legislation, including the UK GDPR and Data Protection Act 2018.

You can read more on our Quality Assurance and Compliance page.

Reviewed by Stephanie Austin, Owner and Lead Trainer, Prima Cura Training | 25+ years in health and social care | 15+ years as a trainer | Last reviewed: April 2026 | Next review: April 2027

This page is for general guidance only and reflects current UK legislation, CQC guidance, and data protection law at the date of review. It does not constitute legal or regulatory advice. Reporting, Record Keeping and Information Governance in Care Training provides awareness and practical guidance for care staff and does not replace organisational policies, legal responsibilities, or regulatory requirements under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Providers remain responsible for ensuring their documentation systems, information governance arrangements, and staff training comply with all applicable legislation and CQC expectations.

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