The Importance Of Good Record Keeping In Your Care Business

Records are one of the main focus areas during a CQC inspection and one of the main sources of evidence that the CQC relies on when determining if a service is Safe, Effective, Caring, Responsive and Well-led. It is therefore important that records are as accurate and detailed as they can be.

In February 2023, the Local Government and Social Care Ombudsman (“Ombudsman”) issued guidance for care providers in relation to record keeping. The guidance titled ‘Good record keeping: Guide for care providers’ (February 2023) (“Guidance”) is a useful document for providers to refer to. The Guidance states that the Ombudsman regularly receives complaints about residential and domiciliary care services where part of the complaint relates to the information held by the care provider. The Guidance states that among the complaints upheld by the Ombudsman, the common things that it sees go wrong relate to the following areas:

• Not keeping comprehensive records
• Not ensuring records are accurate
• Not retaining relevant information for action.

The case studies covered in the Guidance relate to various issues regarding records including; amending records following a serious incident, service users being given wrong or no medication or food because records were not updated properly.

What Do The Regulations Say?

Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014,  sets out the requirement for providers to, “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.”

When assessing compliance with Regulation 17, the CQC expects records to be fit for purpose i.e.  complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.

Moving From A Paper Based Record System To An Electronic System

The Guidance states that, “the use of digital records is a factor in some of our cases. In some, providers have moved to, or are in the process of moving to, electronic systems of record keeping. And in others, providers have reflected on our investigation and said they planned to invest in electronic systems that promise to support more secure and robust processes.” If a provider is in the process of moving from a paper based records system to a digital system, it is important that the transition is as smooth as possible and that risks are managed appropriately. From a risk management perspective, staff should know where to record information and where to find it.

The Ombudsman acknowledges that a digital record system is not necessarily better than a paper based system. The Guidance states that, “electronic systems do not automatically mean records are of a high quality. In some investigations, the electronic system has encouraged a formulaic data response and the opportunity, for example, of a free text commentary has not been used.” This links with what we have seen providers criticised for. An example is when staff complete an electronic record at the same time so it looks as though care were being provided to five service users at 7.30am, when that cannot be the case. This can be problematic in situations where external professionals such as the CQC, Ombudsman or Coroner (in situations where a death is being investigated) examine records to ascertain what happened to whom, when, where and how. Care records form vital contemporaneous evidence and enable the investigator to understand the action staff took in relation to the care provided to a service user.

It is important to note that the same requirements apply for records whether they are electronic or paper based. Records should be accurate, complete and contemporaneous.

What Happens When The CQC Inspection Team Review Records?

Under the CQC’s current regulatory model, there is a focus on risk based inspections. During an inspection, inspectors will spend time observing care practice, speaking with staff and service users and reviewing care records. Record keeping is an integral part of care practice because they show how care has been assessed and planned. It is therefore important that records are clear and accurate. An external healthcare professional should be able to come into a care setting and from the contents of the record reviewed, be able to determine what care is being provided to which service user. A member of agency staff should be able to easily provide care themselves based on what is written in the care documentation.

Very often things are not recorded and there are gaps in records. This then leads inspectors to take the view that ‘if it’s not written, it didn’t happen’. The Ombudsman also raised similar concerns about gaps in records. The Guidance states that, “Any gaps in records cast doubt on the integrity of the whole care provider record. This may lead us to criticise the provider and make recommendations for apologies, training and practice changes.”

It is therefore important that there is a big emphasis on the importance of record keeping in care services. Providers should tackle this issue head on and remind staff that records are at the heart of providing person-centred care to service users and it is of paramount importance that they are accurate. To support staff with record keeping, providers might want to conduct refresher ‘record keeping’ training and refer to the real life examples in the Guidance regarding what happens when things go wrong with records. Another way to remind staff about good record keeping is to inform them during team meetings or via staff newsletters.

There is usually a link between a provider’s CQC rating for the domains Safe and Well-led so if a provider is rated ‘Requires Improvement’ or ‘Inadequate’ for the domain Safe, they are likely to receive the same rating for the Well-led domain. In the context of record keeping, auditing records remains the best way to assure inspectors that a service is safe. It  is a good idea for providers to review a sample of records on a monthly and quarterly basis to ensure that staff have completed them correctly. In turn this will help to demonstrate compliance with Regulation 17.

Conclusion

The problem with poor record keeping is that it can lead to the CQC and Ombudsman reaching incorrect conclusions about the care being provided in a service. Providers should therefore take it seriously and support staff with the record keeping process. Records should be accurate, up to date and reviewed regularly.

If providers would like help with or advice on how to deal with Ombudsman complaints or the CQC’s inspection activity generally, we can help.