Digital Records Management Policy

1. Purpose

The purpose of this policy is to ensure that all care records, safeguarding documents, risk

assessments, and operational files are created, stored, maintained, and accessed digitally in a

way that complies with:

CQC Fundamental Standards

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

UK GDPR and Data Protection Act 2018

Data Use and Access Act 2025

Reasonable Adjustment Digital Flat 2026

NHS Records Management Code of Practice

Information Governance and cybersecurity best practice

This policy ensures digital records are safe, accurate, accessible, and person‑centred.

2. Scope

This policy applies to all staff, contractors, and professionals who access or manage the

agency’s digital systems and care records.

3. Policy Statement

The agency operates a digital‑first, paperless records system . As stated in the original

document:

“All care documentation is created, stored, and maintained electronically. Paper

copies are only produced when specifically requested by external professionals.”

Digital systems are the primary method for recording, storing, and retrieving information.

4. Standards

Updated Feb 2026 Fay Townsend-JacksonDigital Records Management Policy

4.1 Record Quality

The original policy states:

“Records must be accurate, contemporaneous, and complete.”

All digital entries must be factual, timely, person‑centred, and compliant with professional

standards.

4.2 Digital Security

Role‑based access controls

Multi‑factor authentication

Full audit trails

Encrypted storage and transmission

Automatic, monitored backups

Secure disposal of digital data

4.3 File Structure & Naming

Staff must follow the approved file structure and naming conventions to ensure consistency and

rapid retrieval.

4.4 Inspection Readiness

Your document states:

“Inspectors must be able to access required information quickly and without delay.”

Digital systems must remain organised, searchable, and accessible for regulatory inspections.

5. Legislative & Regulatory Compliance

5.1 CQC Regulations

This policy supports compliance with the Health and Social Care Act 2008 (Regulated Activities)

Regulations 2014, including:

Updated Feb 2026 Fay Townsend-JacksonDigital Records Management Policy

Regulation 9 – Person‑Centred Care

Regulation 12 – Safe Care and Treatment

Regulation 17 – Good Governance

(Supported by your policy requirement that

“Records must be accurate, contemporaneous, and complete.”)

5.2 Data Protection & Information Governance

UK GDPR & Data Protection Act 2018

All digital records must comply with:

Lawful bases for processing

Data minimisation

Accuracy

Retention

Security

Rights of the data subject

Data Use and Access Act 2025

The agency will:

Maintain transparent data‑sharing practices

Provide clear explanations of how data is used

Maintain detailed audit logs

Restrict and monitor third‑party access

Ensure data‑processing agreements with all digital providers

Data Security & Protection Toolkit (DSPT)

The agency will complete the DSPT annually.

Caldicott Principles

All digital recordkeeping must follow the seven Caldicott principles.

Updated Feb 2026 Fay Townsend-JacksonDigital Records Management Policy

5.3 Accessibility & Equality

Equality Act 2010

Requires reasonable adjustments for disabled staff and service users.

Reasonable Adjustment Digital Flat 2026

The agency will:

Ensure digital systems are accessible

Provide alternative formats and assistive technology

Make reasonable adjustments to digital workflows

Train staff in inclusive digital practice

5.4 Digital & Cybersecurity Standards

Compliance includes:

Network and Information Systems (NIS) Regulations 2018

Cyber Essentials / Cyber Essentials Plus

NHS Digital interoperability standards

ICO cybersecurity guidance

Your document already supports this by stating:

“Digital files must be secure, with role-based access and audit trails.”

5.5 Records Management & Retention

NHS Records Management Code of Practice 2021

Electronic Communications Act 2000

Freedom of Information Act 2000 (where applicable)

Updated Feb 2026 Fay Townsend-JacksonDigital Records Management Policy

5.6 Safeguarding & Duty of Candour

Care Act 2014

Children Act 1989 & 2004

Regulation 20 – Duty of Candour

Digital safeguarding records must be secure, accurate, and promptly updated.

6. Roles & Responsibilities

Registered Manager

Ensures compliance with legislation and CQC requirements

Oversees digital governance and audits

All Staff

Maintain accurate digital records

Follow security protocols

Report breaches or concerns

Use only approved systems

IT / System Administrators

Maintain secure system configuration

Monitor backups and access logs

Support accessibility and reasonable adjustments

7. Training

All staff must complete training on:

Digital recordkeeping

GDPR and data protection

Cybersecurity

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Accessibility and reasonable adjustments

CQC compliance

8. Monitoring & Audit

Regular audits of accuracy, completeness, and compliance

Review of access logs and permissions

Annual DSPT submission

Findings used to improve practice

9. Review

This policy will be reviewed annually or sooner if legislation, technology, or regulatory

requirements change.

Updated Feb 2026 Fay Townsend-Jackson