The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 No. 1264 (W. 295)

Regulation 59

SCHEDULE 2 Records to be kept in respect of regulated services

PART 1 Records to be kept in respect of all regulated services

1.  In respect of each individual, records of—

(a) all relevant assessments;

(b) personal plans;

(c) reviews of personal plans;

(d) care and support plans;

(e) reviews of care and support plans;

(f) care provided, including daily records or records of specific care interventions;

(g) correspondence, reports and records in relation to additional support provided by education, health and other allied services.

2.  A record of any charges by the service provider to individuals for the provision of care and support and any additional services.

3.  A record of all medicines kept in the service for each individual and the date and time on which they were administered to the individual.

4.  A record of all money or other valuables deposited by the individual for safekeeping or received on the individual’s behalf, which must include a record of—

(a) the date on which the money or valuables were deposited or received;

(b) the date on which any money or valuables were—

(i) returned to the individual, or

(ii) used, at the request of the individual, on their behalf;

(c) where applicable, the purpose for which the money or valuables were used;

(d) the written acknowledgment of the return of the money or valuables.

5.  A record of the following events that occur in the service—

(a) any serious accident, injury or illness which is significantly detrimental to the well-being of an individual;

(b) the outbreak of infectious disease in the service;

(c) any theft or burglary;

(d) any safeguarding referral made in respect of an individual;

(e) falls and consequent treatment provided to an individual;

(f) incidence of pressure ulcers and of consequent treatment provided to an individual;

(g) date and circumstances of any measures of control, restraint or discipline used on an individual.

6.  A record of every fire practice, drill or test of fire equipment (including fire alarm equipment) conducted in the service and of any action taken to remedy defects in the fire equipment.

7.  A record of all complaints made by individuals or their representatives or by persons working at the service about the operation of the service, and the action taken by the service provider in respect of any such complaint.

8.  A record of all persons working at the service, which must include the following matters—

(a) the person’s full name, address, date of birth, qualifications and experience;

(b) a copy of the person’s birth certificate and passport (if any);

(c) a copy of each reference obtained in respect of the person;

(d) the dates on which the person commences and ceases to be so employed;

(e) the position the person holds at the service, the work he or she performs and the number of hours for which he or she is employed each week;

(f) records of disciplinary action and any other records in relation to the person’s employment;

(g) a record of the date of a DBS certificate and whether there was any action taken as a result of the content of the certificate.

9.  A copy of the duty roster of persons working at the service, and a record of whether the roster was actually worked as intended.

PART 2 Additional records to be kept in respect of care home services, secure accommodation services and residential family centre services

10.  A record of any furniture brought by an individual into the room occupied by him or her.

11.  A record of any of the following events that occur in the service—

(a) any fire;

(b) unexplained or unauthorised absence;

(c) death of an individual.

12.  A record of all visitors to the service, including the names of visitors and the persons they are visiting.