Why Record Keeping Is Important.

At Bettal, we specialise in writing high quality CQC compliant social care policies and procedures, as well as providing a host of other documents to help busy managers keep abreast of their record keeping obligations.

We recognise, because our clients tell us, that keeping staff engaged with record keeping is one of the most difficult parts of the role of the Registered Manager. In part this is because carers are busy and would rather use their time to undertake their care tasks and in part because some carers don’t see the point of record keeping.

Telling staff that record keeping is part of their job just won’t cut the mustard with the more reticent staff members who argue that record keeping doesn’t improve care. So what does one do?

In this blog we will have a look at how you might approach this topic with the reticent carers and those who create records which are not perhaps as good as they ought to be. We will suggest some powerful reasons as to why carers need to keep good records.

Understanding the Purpose of Social Care Records

There are a number of very good reasons that care records, we will have a look at a few of these here:

It proves care happened

We have all heard the old adage: “if you did not write it down, it did not happen”. While this is not 100% true, it is true enough to use as a means of starting to show the reluctant record keeper that they have to record the care they give. This is especially poignant when one points out who the carer may have to prove that they undertook care to, this includes:

• The Care Quality Commission (CQC), or another regulator.
• The Coroner, usually in Coroner’s Court.
• The Police, often under caution when something goes wrong.
• A Judge in Civil or Criminal Court
• Angry family members/friends.
• The Service User.
• Their Employer.
• If they are a healthcare registered professionals, their regulator.

While we all hope never to get into any form of trouble over the care we provide, there may be times in our career when we are asked, justly, to prove and justify our actions. In many cases, contemporaneous records are taken to be the ultimate proof that something happened, including, for example, the delivery of care at a certain time, to a certain person and in a certain way.

To Support Person-Centred Care

How do records support person-centred care? Person-centred care (PCC) is one of the CQC fundamental standards. PCC is that care which is provided to meet the specific identified needs and preferences of an individual Service User.

Staff can only act in person-centred ways if they know what the person wants and prefers in the way of care; that is when the care plan is clear in identifying this. In this case the good records are the care and support plans and risk assessments underpinning care.

To Support Continuity of Care

Good care plans and risk assessments also support continuity of care between carers. This means Service Users get the care they need in the ways they prefer time and time again. Continuity is promoted when carers are guide din their caring endeavours by all following the same clearly recorded care plans.

Both person-centred care and continuity of care are also underpinned by robust and timely carer notes which can be used to inform handovers and the updating of care and support plans and risk assessment.

To Support Service User Safety

If records, like risk assessments, are put of date or incomplete, then the Service User is put at risk of harm. Risk assessments especially are important in providing care staff with guidance about the care and support of Service Users who are at specific risk of harm, for example from falls or bleeds.

Without these risk assessments staff would not know what to look out for, nor would they know how to behave if the risk materialises. In this way, good records help care staff with informed decision-making .

Helping Staff With Record Keeping

Once staff understand the importance of care records, they are more likely to make timely entries which are informative and of benefit to the client. Record keeping can be challenging for some care staff who may need support to create care and handover notes.

Managers should always ensure they are aware of staff who may have a need for support with reading and writing, and ensure they have access to voice notes when using digital care records or other means of recording notes if they use paper, for example digital voice recorders with encryption (see link here).

Summary

We have identified why record keeping in care is important. We have identified that as well as it being important for service user care, in terms of continuity and person-centeredness, record keeping may be important in managing a complaint or an investigation by a regulator, the police or the courts.

In a later blog in this series, we will consider what good record keeping requires of social care staff and how to make good quality care records.

Bettal Quality Consultancy has a comprehensive and regularly updated suite of policies, procedures, risk assessments and comprehensive documentation tailored to all forms of social care provision, to support busy registered managers and their teams achieve CQC compliant care.

Contact Bettal Quality Consultancy today to learn how our comprehensive and value for money policies and procedures can help you achieve successful care provision and CQC compliance.

Browse our website.

Email us at info@bettal.co.uk.

Or call us at 016977 41411 to get started!

Peter Ellis MA MSc BSc(Hons) RN
Consultant
Bettal Quality Consultancy