Reporting, Record Keeping & Information Governance in Care
Reporting, record keeping and information governance training delivered at your workplace or remotely. Half a day or a full day. What good documentation actually looks like in practice, and the data protection responsibilities every care worker carries when they write a record.
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 how safeguarding investigations work, how CQC inspections go, and how legal proceedings operate. In delivery, the consequences of poor recording are consistent and serious: incomplete records mean the care worker coming on shift doesn’t have the full picture, and a change in someone’s condition, missed on one record and not picked up on the next, goes unaddressed. This happens. It’s preventable. And the responsibility sits with every member of staff who writes a care record.
Poor record-keeping is not an admin problem. It’s 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: 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.
This 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 Microsoft Teams
- Certificate: CPD-Accredited Certificate of Achievement in Reporting, Record Keeping and Information Governance in Care
- Awarding organisations: CPD-Accredited
- Validity: Refresher 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
- Group size: Maximum 15 learners per trainer
Who This Course Is For
This course is right for anyone who writes, reads, or contributes to care records, in any setting.
- 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’s 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. If your team’s challenges centre more on the care planning process itself rather than day-to-day recording, our Care and Support Planning course may be the better starting point.
Why This Training Matters
Accurate, complete, and timely documentation is one of the fundamentals of safe care. It keeps the next person informed, flags what has changed, and 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 CQC Regulation 17: Good Governance, providers have a legal duty to maintain accurate, complete, and contemporaneous records for each person using the service. This isn’t guidance or best practice. It’s 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.
The data protection side is equally significant. The UK GDPR and Data Protection Act 2018 require that personal data, including care records, is processed lawfully, stored securely, kept accurate and up to date, and shared only where there’s an appropriate legal basis. In a care setting, every member of staff who handles personal information carries legal responsibilities that go beyond good intentions.
Care Certificate Standard 14 and This Course
Care Certificate Standard 14 (Handling Information) sets out the expected knowledge and competence for care workers in relation to keeping information about individuals confidential, understanding when information can and must be shared, and following their employer’s information handling policies and procedures. This course covers Standard 14 in full, alongside the wider UK GDPR and Data Protection Act 2018 requirements that sit behind it.
For a complete guide to the Care Certificate, all 16 standards, and how Prima Cura Training supports organisations to deliver and assess it, visit our Care Certificate UK Guide.
What the Day Covers
All content reflects CQC Regulation 17, the UK GDPR, the Data Protection Act 2018, and Care Certificate Standard 14 throughout. Topics covered include:
- The role of documentation in safe care: why records matter and what happens when they don’t reflect reality
- Principles of good record keeping: accuracy, objectivity, completeness, timeliness, and consistency
- Factual and objective recording: the difference between what was observed and what was assumed
- Common documentation errors: vague language, incomplete entries, opinion presented as fact, and judgmental recording
- Incident reporting: what to record, when to record it, and how it supports both individual safety and organisational learning
- Communication between shifts: how records function as a handover tool
- Care Certificate Standard 14: confidentiality, information sharing, and the expectations placed on care workers
- UK GDPR and Data Protection Act 2018: the legal principles governing personal data in a care setting
- Secure storage and handling of personal information
- Sharing information appropriately: when information can and must be shared, and how to document that decision
- CQC Regulation 17 and the Good Governance standard: what it requires and how it’s assessed at inspection
- Legal and regulatory context: the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Every course is also built around your documentation systems, formats, and reporting procedures as standard.
How the Course Is Delivered
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.
Groups are capped at 15. 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, and practical exercises in factual and objective recording, including identifying and correcting common errors.
Where helpful, we incorporate your own care records, documentation formats, and organisational policies on confidentiality and data protection directly into delivery. For services wanting a joined-up governance and compliance programme, this course also combines well with our Person-Centred Care and Planning, Adult Safeguarding Level 1 and 2, and Duty of Care courses.
Care Sector or General Business Training?
Reporting, Record Keeping and Information Governance in Care (this course): Covers the same legal and documentation principles, built specifically around CQC Regulation 17, Care Certificate Standard 14, and the realities of care planning, incident reporting, and safeguarding documentation. Right for care homes, domiciliary care providers, and supported living services.
Reporting, Record Keeping and Information Governance: Covers the same core principles of good documentation and data protection, written for general business, office, and operational settings. Right for organisations outside health and social care, or for mixed teams where most staff aren’t working directly in care delivery. See our Reporting, Record Keeping and Information Governance course for that version.
Both courses cover the UK GDPR and the Data Protection Act 2018 in full. The difference is context and regulatory framing, not depth.
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.
Why Organisations Book With Prima Cura
Most training providers arrive with a course. We arrive with yours.
Before the day, we gather information about your workplace: your incident reporting forms, your internal procedures, and the specific hazards your team actually faces. On the day, your trainer works that into every scenario, every discussion, every practical exercise. If your staff work in a care home, they’re not practising on hypothetical office workers. If your team are lone workers, that context shapes how the session runs.
It means the training lands. Not because it was well-delivered in a generic sense, but because it was relevant to the people in the room and the situations they’ll actually encounter.
A few other things that matter to the organisations that book with us:
- 98.9% learner satisfaction across all Prima Cura courses
- All trainers hold Enhanced DBS certificates and maintain ongoing CPD
- We advise honestly on the qualification level at the enquiry stage. If a different course is a better fit for your workforce, we’ll say so before you book, not after
We respond to all enquiries within one working day.
Where We Deliver
We deliver in-house training at your workplace or chosen venue across Manchester, Greater Manchester, and the wider North West. We also deliver nationally across England, including North England, South England, London, and Surrey.
All sessions are led by experienced Prima Cura Training instructors. Groups are capped at 15 per trainer to protect the quality of hands-on learning.
Our associate network means we can deliver across England. You can meet the team on our Associates page.
FAQs
What does Regulation 17 require in relation to records?
CQC Regulation 17 (Good Governance), under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, requires providers to maintain an accurate, complete, and contemporaneous record in respect of each service user. This is a statutory requirement, not guidance. CQC inspectors assess record quality directly during inspection, and poor records can contribute to inadequate ratings across multiple key questions.
How does this course cover UK GDPR and data protection?
The UK GDPR and Data Protection Act 2018 require that personal data is processed lawfully, stored securely, kept accurate and up to date, and shared only where there’s an appropriate legal basis. In care, that means every member of staff who handles personal information carries legal responsibilities. This course covers those responsibilities in practical terms, including secure storage, information sharing decisions, and the limits of confidentiality.
Can poor record-keeping lead to safeguarding concerns?
Yes. Incomplete or inaccurate records can conceal risks, delay responses, and contribute directly to harm. A record that doesn’t reflect a change in condition, or that fails to document a concern that was raised, creates a gap in the care that the next person providing support cannot fill. In serious cases, documentation failures form a significant part of both safeguarding investigations and CQC regulatory findings. Our Adult Safeguarding Level 1 and 2 course covers the safeguarding side of this in depth.
Who is responsible for record-keeping in a care setting?
Every member of staff who contributes to someone’s care. Oversight may sit with senior staff and managers, but accountability for individual entries sits with the person who made them. This course ensures all staff understand that their records are a professional and legal responsibility, not an administrative afterthought.
Related Courses
- Person-Centred Care and Planning
- Adult Safeguarding Level 1 and 2
- Duty of Care
- Mental Capacity Act and DoLS
- Confidentiality and Data Protection
Book or Enquire
Book your training or request a quote
Tell us your team size and your sector. We’ll come back with a quote, the right advice on qualification level, and a straight answer on whether this is the best course for your team.
We respond to all enquiries within one working day.
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.
This course is reviewed against updates from the Care Quality Commission and current UK legislation, including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the UK GDPR, and the Data Protection Act 2018. Course content aligns with CQC Regulation 17 (Good Governance) and Care Certificate Standard 14.
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: June 2026 | Next review: June 2027
This page is for general guidance only and reflects current UK legislation, CQC guidance, and data protection law as of 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.
