In the second of a four-part series of features on record keeping, Chris Payne provides guidance on how long care records should be kept.
Hidden away in Prompt 21C of the Care Quality Commission’s Guidance about Compliance: Essential Standards of Quality and Safety, it states the following.
People who use services can be confident that:
their social care records for adults are kept or disposed of in accordance with the Data Protection Act 1998 and three years from last date of entry
their social care records for children are kept or disposed of in accordance with the Data Protection Act 1998 and 80 years from last date of entry.
There are two key aspects to this statement. First is the keeping or disposal of records, which has to follow rules of safekeeping and confidentiality. Second is the length of time that records must be kept after people have stopped receiving the service. After this period, the care service should dispose of the records in a safe, confidential manner. It can have them destroyed, eg by confidential shredding or, if they are in electronic form, deleted from the computer archive. This will usually require the help of an IT expert.
The reference to “three years” was written into the Care Homes Regulations 2001 (Regulation 17), which operated under the Care Standards Act 2000. It is not specified in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which have replaced them. It would appear then that the three-year rule has lost its statutory authority, but is kept as a form of standard practice as if it had full legality as previously.
The three-year rule applies, in the majority of cases, to service users who have died or whose case has been closed. Where a service user transfers to another service, it can be assumed that his or her care records will be transferred with him or her. It is possible that someone who was originally admitted to a care home under an intermediate or respite care arrangement is readmitted some years later as a permanent resident. Under the three-year rule, the care home could well have disposed of the person’s original care records and would have to start his or her documentation afresh.
A source of confusion in the interpretation of the three-year rule is that local authorities operate under a different set of rules. Local authorities’ retention and disposal of document schedules for adult care services usually state a six-year period for the retention of service users’ records from the date of “last contact”. To avoid any confusion, it would make sense if there was a common retention period for all social care services as, in practice, the three-year rule will apply only to private and voluntary care services.
Another source of confusion is that the current regulations and guidance do not define or specify what should go into a social care record, which usually consists of several kinds of documents and associated information. Again, the previous regulations were more detailed on the required contents. Schedule 3 of the Care Regulations 2001 required records to include:
means of identification, including a photograph
relevant contact details
dates of entry and departure, eg when transferring to hospital, another care home or another domiciliary care service, or date and time of death with information about cause of death
accident and incident records
records of any restraints and restrictions imposed on a person with or without his or her consent.
These contents were in addition to the needs assessments and service user plans set out as requirements elsewhere in the Regulations.
Care service managers are advised to refer to Schedule 3, which still provides a useful checklist for the required contents of a social care record.
Last reviewed 2 April 2014