Failure to maintain proper records could result in prosecution for care home owners and staff

Every day care home staff are putting themselves and their employers at risk by failing to keep proper records. And as it becomes increasingly common for care homes and individual staff to be taken to court, it has never been more important to have robust defensible documentation in place. In fact, according to Outcome Solutions, the company which helps care homes meet their CQC outcomes, many recent care home investigations and subsequent staff suspensions could have been avoided had proper records been in place.

When stories of suspensions hit the press, the headlines are often very misleading and the public can jump to conclusions. They often assume something sinister has taken place when in fact the staff have been suspended for failing to keep accurate records. The stigma of such a suspension can have a huge effect on the care home and its staff with long-term consequences for both.

So what is the Solution?

Writing care records accurately and maintaining defensible documentation allows care home staff to give a better level of care to service users. The records help provide consistency of care and are crucial for tracking improvements or deterioration in the service user’s condition. But as well as protecting service users, writing care records also has major benefits for staff. The records provide a vital reminder of key information and give staff the peace of mind that every aspect of care has been completed correctly. It also provides them with the necessary evidence to show that they are fulfilling their duties properly during inspections by the Care Quality Commission or other bodies.

Meeting CQC Outcomes The CQC has produced 28 regulations with associated outcomes and care homes and their staff are expected to demonstrate that they are working towards meeting each outcome.

One particular CQC outcome (number 21) relates directly to keeping accurate care records. However keeping high quality records not only meets outcome 21 but also ensures that there is the proper evidence to show that staff are doing their best to meet all 28 of the regulations.

Why are Care Homes Failing to Complete Proper Records? When the benefits of defensible documentation are so clear to see, it may seem surprising that many care homes are failing to complete care records to the necessary standards.

Outcome Solutions believes that it is because writing records or reports does not come naturally to most care home staff. Whilst they may have excellent skills in providing care, many have not received adequate training in writing care records. They may therefore resort to jotting down very short statements such as ‘no problems’ or ‘usual care given’ which will be of little use when being scrutinised as part of an inspection.

By training staff to maintain defensible documentation, employers can instil confidence into their teams, boost morale and provide improved care, all whilst ensuring that they are meeting their legal and moral obligations.

To help care homes meet the CQC outcomes, Outcome Solutions has produced Writing Care Records - a practical training workbook. The workbook is designed to improve the recording skills of care and support workers. It demonstrates why accurate records are essential and teaches staff how to record facts accurately. For more information about Writing Care Records, visit www.outcomesolutions.co.uk

By equipping care home staff with the skills to keep proper records, employers will not only improve the care given and enhance the skills of their workforce but they will also ensure that they have all the correct documentation to hand when asked to produce records during inspections.