CQC and record keeping – If it’s not written down it didn’t happen

The purpose of a CQC inspection is to determine if a service is complying with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. The CQC determines if a service is ‘Good’ by considering five key questions (is the service safe, effective, caring, responsive and well-led?).

A CQC inspection report sets out the good practice that is seen during an inspection as well as any concerns the CQC has. Records are a critical source of evidence that the CQC inspectors rely upon to determine the answers to the five key questions above so it is important to keep detailed and accurate notes.

Reviewing records

CQC inspectors are supposed to corroborate their findings by talking to people (staff, service users and their families), observing care practice and reviewing records. However, often CQC inspectors rely on records as the sole evidence for determining judgements. This means that records are critical in any care setting because they show how decisions relating to service users’ care are made and how care is delivered. On occasion, some things are not recorded and inspectors take the view that ‘if it’s not written, it didn’t happen’.

Record keeping is an integral part of care practice and it is important that records are completed in a timely manner while things are still fresh in your mind. Records should also be clear and accurate. They should be written in such a way that the meaning is clear and abbreviations or jargon should be avoided. A member of agency staff or an external healthcare professional should be able to come into the home, pick up any record and from its contents be able to determine what care is being provided to which service user. Agency staff or external professionals should also be able to easily provide appropriate care themselves based on what is written in the care documentation.

Records should demonstrate how care has been assessed and planned. They should also state what action has been taken in respect of each individual service user and what the outcome of each action was. For example, making appropriate referrals to external professionals where necessary and recording what their advice was and how you acted on it.

The CQC, quite rightly, places increased emphasis on how service users and their loved ones are involved in the planning of their own care. The records should therefore reflect where service users have been consulted and how their individual wishes and preferences have been taken into consideration. All care planning documentation should be produced with the service user at the very centre. Many providers would say that this principle is a “no-brainer” but how many actually record the conversations that are had with service users in this respect? This is the kind of evidence that the CQC will want to see.

Conclusion

We have noticed that gaps in records are commonplace. The problem with poor record keeping is that it can have the very real consequence of the CQC jumping to the incorrect conclusion that medication has been missed or that a service user has not received food or water, when actually, it is simply a case of a staff member who has not marked the sheet appropriately. Providers will attract harsh criticism in an inspection report for such an error and it is likely that the report will not reflect that the problem is down to a minor administrative error. The lasting effect will be a report that suggests that service users are poorly cared for and this will not reflect the hard, practical work undertaken by staff.

In summary, although care staff’s main priority is to provide comprehensive, safe and effective care to vulnerable people, the reality is that the current regulatory framework requires that this care can be evidenced. Providers need to tackle this issue head on and where necessary, provide staff with record keeping training.