Records, investigations, and working with residents and families

Candour relies on accurate records and clear follow-up. CQC requires providers to keep a secure written record of meetings and communications with the relevant person after a notifiable safety incident. For care staff, this begins with accurate contemporaneous notes and honest cooperation with any review or investigation.

What good recording looks like

• Time and sequence: note when the issue was noticed, what was observed, and the steps taken afterwards.
• Direct facts: record what the resident said where relevant and avoid assumptions or blaming language.
• Who was told: list senior staff, external professionals, or family members who were informed.
• Immediate action: record clinical review, first aid, monitoring, replacement medication, or any other interventions.
• Follow-up communication: document meetings, calls and updates, and exactly what was explained to the resident or relevant person.

If a resident lacks capacity, the service may need to work with someone acting lawfully on their behalf, but the resident should still be involved as far as possible and offered appropriate communication support.

For managers and senior staff

Good candour records are factual, timely, and complete. If the record is vague or defensive, the process usually is too.